Clinical Pharmacy Program Guidelines for Calcipotriene
Program
Medication
Pharmacy & Therapeutics
Approval Date
Effective Date
1.
Step Therapy
Calcipotriene cream, calcipotriene ointment, calcitriol
ointment
9/2016
10/2016
Background:
The intent of this policy is to contain utilization of topical calcipotriene and calcitriol to those
who have failed therapy with, or who are unable to receive or tolerate medium to high potency
corticosteroid topical treatments.
Members currently on topical calcipotriene cream/ointment or calcitriol ointment therapy as
documented in claims history will be allowed to continue on their current therapy. Members
new to therapy will be required to meet the coverage criteria below.
2.
A.
Coverage Criteria:
Calcipotriene cream, calcipotriene ointment, or calcitriol ointment
1. Calcipotriene cream, calcipotriene ointment, or calcitriol ointment will be
approved based on all of the following:
a. Diagnosis of psoriasis
-ANDb. History of failure, contraindication, or intolerance to two medium to high
potency corticosteroid topical treatments
Authorization will be issued for 12 months.
3.
Additional Clinical Rules:

Supply limits may be in place.
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Additional Information
Table 1. Relative Potency of Selected Topical Corticosteroid Products
Drug
Dosage Form
Strength
Very High Potency
Augmented betamethasone
Ointment
0.05%
dipropionate (Diprolene)
Clobetasol propionate (Temovate) Ointment
0.05%
Diflorasone diacetate (Psorcon)
Ointment
0.05%
Halobetasol propionate (ultravate) Cream, Ointment
0.05%
High Potency
Amcinonide (Cyclocort)
Augmented betamethasone
dipropionate (Diprolene,
Diprolene AF)
Betamethasone dipropionate
(Diprosone)
Betamethasone valerate
(Valisone)
Desoximetasone (Topicort)
Diflorasone diacetate (Florone,
Maxiflor)
Fluocinolone acetonide (Synalar)
Fluocinonide (Lidex)
Halcinonide (Halog)
Medium Potency
Betamethasone dipropionate
(Diprosone)
Betamethasone valerate
(Valisone)
Betamethasone valerate (Luxiq)
Clocortolone pivalate (Cloderm)
Desoximetasone (Topicort)
Fluocinolone acetonide (Synalar)
Flurandrenolide (Cordran)
Fluticasone propionate (Cutivate)
Cream, Lotion,
Ointment
Cream
0.1%
Cream, Ointment
0.05%
Ointment
0.1%
Cream, Ointment
Gel
Cream, Ointment
(emollient base)
Cream
Cream, Ointment, Gel
Cream, Ointment
0.25%
0.05%
0.05%
Lotion
0.05%
Cream
0.1%
Foam
Cream
Cream
Cream, Ointment
Cream, Ointment
Cream, Ointment,
Lotion
Cream
Ointment
0.12%
0.1%
0.05%
0.025%
0.025%
0.05%
0.05%
0.2%
0.05%
0.1%
0.05%
0.005%
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Hydrocortisone butyrate (Locoid)
Hydrocortisone butyrate
(Westcort)
Mometasone furmoate (Elocon)
Ointment, Solution
Cream, Ointment
0.1%
0.2%
Cream, Ointment,
0.1%
Lotion
Triamcinolone acetonide
Cream, Ointment,
0.025%
(Aristocort, Kenalog)
Lotion
0.1%
Cream, Ointment,
Lotion
Reference: Corticosteroids Topical Monograph, Facts and Comparisons 2007
4.
References:
1. National Psoriasis Foundation. About psoriasis. Statistics. Available at
http://www.psoriasis.org/about/stats/. Accessed on April 2nd 2009
2. Micromedex [Internet database]. Greenwood Village, Colo: Truven Health Analytics.
Updated periodically. Accessed January 9, 2015.
3. USP DI Volume I: Drug Information for the Health Care Professional [Internet database].
Greenwood Village, Colo: Thomson Micromedex. Updated periodically. Accessed
November 30, 2006.
4. McEvoy GK. AHFS Drug Information 2010. Bethesda, MD: American Society of
Health-System Pharmacists, Inc; 2010.
5. Drugs for Acne, Rosacea and Psoriasis. Treatment guidelines from the Medical Letter.
2005. 3(35): 49-56.
6. American Academy of Dermatology. Psoriasis. Available at:
https://www.aad.org/education/clinical-guidelines. Accessed January 9, 2015.
7. Mentor A, Korman N, Elmets CA, et al. Guidelines of care for the management of
psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and
treatment of psoriasis with topical therapies. Amer. Acad. of Derm. 2009;60:643-59.
8. Calcitrene Prescribing Information. Taro Pharmaceuticals, April 2012.
9. Dovonex Prescribing Information. Leo Pharma, June 2014.
Program
Date
9/2016
Step Therapy - Calcipotriene cream, calcipotriene ointment,
calcitriol ointment
Change Control
Change
New Program
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